WellFirst by Medica Bronze Copay Plus 9400X (Free Virtual Visits)

Health Insurance Plan Details (2024 Plan)

Monthly Premium

HMO
$ubsidy
Bronze
Deductible
$9,400 /yr
Max Out-of-Pocket
$9,400 /yr

Details

Deductible (per individual) $9,400 /yr
Deductible (per family) $18,800 /yr
Max Out-of-Pocket (per individual) $9,400 /yr
Max Out-of-Pocket (per family) $18,800 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $40 Copay
Specialist Visit $80 Copay
Emergency Room No Charge after Deductible
Inpatient Facility No Charge after Deductible
Inpatient Physician No Charge after Deductible
Drug Costs
Generic Drugs $25 Copay
Preferred Brand Drugs $200 Copay
Non-preferred Brand Drugs $300 Copay
Specialty Drugs $450 Copay

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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